Dissociation and its Types

What is Dissociation?

The term dissociation refers to the human mind’s capacity to engage in complex mental processes, which are split off from, or not in touch with conscious awareness. The concept of dissociation was first looked at, over a century ago by French neurologist Pierre Janet in 1859. Dissociation was once classified as hysteria. The 1970s witnessed an epidemic of dissociation which reflected enthusiasm for the diagnosis more than its actual prevalence. Traditionally, dissociation has been attributed to trauma and other psychological stress. The truth is, we all dissociate to a degree from time to time. Mild dissociative symptoms occur when we daydream or lose track of what is going on around us, or when we unknowingly miss part of a conversation that we are engaged in. Dissociation only becomes concerning, or pathological when the symptoms are disruptive, and  invoke a loss of needed information, producing discontinuity of experience. They could also be recurrent, and jarring involuntary intrusions into any executive functions, and sense of self.

There is actually nothing inherently pathological about dissociation itself. Everyone experiences unconscious mental processes that seem implicit to a significant degree. These processes are relevant to areas of implicit memory and perception, where it can be demonstrated that everyone does show some evidence of remembering things they cannot consciously have access to. We also respond to sights or sounds as if we had perceived them even though it cannot be reported that they we seen or heard them.

Dissociative Disorders

Dissociative disorders are a group of mental disorders which disrupt a person’s regulated functions of consciousness, memory, identity, or perception. Dissociative disorders are also often characterized by a discontinuity in body representation, motor control, and behavior. Dissociative symptoms, if untreated, can potentially disrupt every area of psychological functioning of an individual.

In people with dissociative disorders, the normally integrated human cognition becomes much less coordinated and systematic. Due to this, the individual might not be able to access the information that is normally present in consciousness, such as their personal identity or the details of an important chunk of time in the recent past. This impairment in cognition is sometimes due to management of severe psychological threats. Dissociative disorders appear mainly as unconscious coping mechanisms for anxiety and stress, or to handle life events that might exceed the person’s usual coping resources.

Dissociative symptoms are experienced as prominent intrusions into one’s awareness and behavior, with accompanying loss of continuity in one’s experience. Symptoms can be distinguished by positive and negative symptoms. Positive refers to the addition of undesirable elements into one’s cognition. Positive dissociative symptoms can be explained with examples such as fragmentation of identity. Negative symptoms are subtractions of imperative elements from one’s cognition or behaviour. They can include inability to access information or have control of mental functions. Amnesia can also be a negative symptom of dissociative disorder.

The dissociative disorders are often found in the aftermath of deeply traumatic events. Many of the symptoms, which might include embarrassment and confusion, or a desire to hide them, are influenced by the experience of said trauma. As dissociative disorders are caused by trauma, a significant part of the clinical consequences of deeply rooted childhood trauma, have to be considered and treated appropriately by trained mental health professionals in order to get to the base of the issue.

Studies conducted have also established a connection between childhood trauma and the development of dissociative disorders in adults. Several clinicians are also identifying dissociative symptoms in abused children, and there is strong evidence that dissociative disorders are starting to represent an unrecognized form of psychopathology in children with experiences of trauma. Pathological dissociation is seen as a complex inherent process, that leads to an inability to integrate information into the normal level of consciousness. Many of these symptoms and behaviours are also unfortunately misdiagnosed as need for attention, learning or conduct problems, or even psychosis.

Types of Dissociative Disorders

There are several types of dissociative disorders that exist. They include depersonalization/derealization, dissociative amnesia, dissociative fugue and dissociative identity disorder.

1. Depersonalization/Derealization

Depersonalization refers to experiences of detachment from reality, or feeling like an observer from outside with respect to one’s thoughts, feelings, sensations, body, or actions. Examples of this can include perceptual alterations, distorted sense of time, unreal or absent self, emotional and physical numbing.

Derealization refers to having experiences of detachment from reality from one’s current surroundings. Examples of derealization include individuals or objects being experienced as unreal, dreamlike, foggy, lifeless, or visually distorted.

The symptoms of this disorder usually cause clinically significant distress or impairment in social, occupational, or other important areas of functioning It is important to note that they are not attributed to use of substances. People who struggle with this disorder often report having persistent and recurrent experiences of feeling detached from their own bodies and also their mental processes. The object that is the centre of the experience, which is the self in depersonalization, or the world in derealization, is often described by individuals as isolated, lifeless, strange,and unfamiliar, behaving mechanically, without any self-control. Some patients also report feeling as if they are living in a dream or movie, and not their real life. The age of the onset of depersonalization/derealization disorder is 16 years, but the disorder can start in early or middle childhood.

1. Dissociative Amnesia 

Dissociative Amnesia is the inability to recall autobiographical information that must be inconsistent with normal forgetting. The symptoms cause a significant amount of distress and an impairment in social, occupational, or other important areas of normal functioning. They are also not attributed to the use or abuse of substances. This kind of amnesia can be localized, which means only relevant to a specific event or period of time. Or, it can be selective, which means only applicable to a specific aspect of an event. In some cases, it could also be generalized, meaning loss of recall of one’s entire identity and life history.

Retrograde amnesia is known as the partial, or rarely total inability to remember previously acquired information or one’s past experiences. On the other hand, Anterograde amnesia refers to the partial or total inability to retain new information. Some individuals who experience amnesia, notice that they seem to have “lost time”  or that they have a gap in their memory. Although, most individuals with dissociative disorders are usually initially unaware of their amnesia.

Awareness of experiencing amnesia comes around only when one’s personal identity is lost, or when circumstances make these people aware of the fact that their autobiographical information is missing. Localized and selective amnesia is quite common, but generalized amnesia is very rare. Episodes of said amnesia can last between a few days to a few years. Although many people go through only one such episode, some people experience multiple episodes in their lifetimes.

Localized Amnesia- The most experienced form of Dissociative Amnesia

Localized amnesia is known as the inability to remember events that happened in a specific period of time, which is usually centered on a highly distressing or a disturbing event. It often begins and ends rather abruptly, and particularly when it occurs in response to an overwhelmingly traumatic event. People vary in the degree of memory that they lose in localized amnesia. Some individuals might display systematized amnesia, which refers to the loss of memory for only certain categories of information. They also may be unable to recall  certain memories of their families, or of a specific person.

Looking at an example, shortly following the sudden death of her only daughter, an elderly woman suddenly had no recall of having had a daughter, but her other memories were untouched and  unaffected. On the other, selective amnesia works differently. In one case, a man was able to remember having been part of an automobile accident, but he was not able to  recall that his child had unfortunately died in the crash. Selective amnesia is usually experienced by those who have been accused of participating in violent criminal offenses. It was found that many murderers reported remembering having arguments, but did not remember killing anyone.

1. Dissociative Fugue

Dissociative fugue is a rather unusual dissociative disorder which is characterized by amnesia combined with a sudden unexpected travel away from the individual’s local area. There is denial of all memory of the individual’s whereabouts during this period of purposeful wandering. Dissociative fugue is a very rare disorder and is reported very infrequently.

The French word fugue, means flight. Thus the actions in this disorder are a defense by actual flight. The individual is not only amnesic, but they also consciously depart from their usual surroundings. This is also accompanied by significant confusion about personal identity, or even, quite strangely, an assumption of a new identity taken on. During fugue, individuals are not aware of said memory loss for past stages of their life.

Although, their memory for the occurrences during the fugue state, remains intact. Their behavior during the fugue state reflects an extremely different lifestyle from their initial one. After days, weeks, or sometimes even years, these individuals may suddenly come out of this fugue state and may find themselves in a different, odd place, with a different job, and no clue of how they managed to get there. Recovery from fugue state takes place only after repetitive and persistent questioning, or reminders of who they actually are.

1. Dissociative Identity Disorder

Dissociative identity disorder, which was previously referred to as Multiple Personality Disorder, is a significant and extreme manifestation of two or more distinct identities or personalities, which alternate in taking control of the individual’s outward behavior. These extra or alter identities take control at different points of time, and switches between identities occur very quickly, in a matter of seconds. Although, more slower paced switches might also occur. When these switches occur, it is very simple to observe certain gaps in the memories for things that have happened. It is often for things that have happened to the alter identities. The fragmentation of one’s identity varies in relevance to culture.

Many individuals with this disorder have reported experiencing trance-like states, sleepwalking, paranormal-like episodes, and high prevalence of post-traumatic stress disorder. In situations where two or more personalities are observed, only one personality is noticeable at a given moment. However, one or more personalities can be aware of the other’s existence. The personalities often differ from each other. Most of the time, they are direct opposites. In several cases, the alternate personality is manifested in order to protect the emotional state of the original personality from clinically significant stress or trauma. The entire process of dissociation, and the act of switching to an alter, often occurs during situations that are highly stressful. They may be preceded by observed trance- like behavior, blinking eyes, or a change in posture.

Prevalence of Dissociative Identity Disorder-  Is it a ‘Real’ Disorder?

There is considerable argument around the existence of dissociative identity disorder. The clinical relevance of this disorder is largely influenced by the extent to which this phenomenon is acceptable or tolerable, as a legitimate mental illness by its bordering cultural context. Nevertheless, the disorder has now been recognized in almost all cultural groups and socioeconomic groups across the world, where it has been observed. For example, it has been identified in countries like Nigeria, Ethiopia, Turkey, India, China, Australia, and the Caribbean (Maldonado et al., 2002; Xiao et al., 2006). Several related phenomena, like spirit possession and trance states, occur frequently in different parts of the world where their surrounding culture has sanctioned them (Krippner, 1994; Spiegel et al., 2011).

Trance and possession states, when entered into voluntarily, are not really considered pathological. They should not be categorized as mental disorders. However, those who enter into these states voluntarily due to their cultural norms, develop stress and cognitive impairment. The standard diagnostic criteria for the disorder has been changed to include phenomena which are associated with spirit possession.

A trance occurs when one experiences a temporary change in their state of consciousness or identity, but without replacement with an alternative identity. It is associated with  narrowing awareness of one’s surroundings, or stereotyped behaviors which are experienced and are beyond immediate control. A possession trance is similar, but the consciousness or identity is replaced with a new identity which is attributed to the influence of a spirit, deity, or higher power. There is amnesia as well. A study individuals with this diagnosis, as well as individuals with a diagnosis of depression, found that religious or cultural conflicts were most predictive of who had dissociative trance disorder and who had major depression (Ng & Chan, 2004).

A study on dissociative trance and possession disorders found that migration and struggles with assimilation to a different culture, are associated with these disorders (During et al., 2011). In comparison with high reported rates of dissociative identity disorder in Western cultures, a study with patients with a diagnosis of some type of dissociative disorder at an Indian psychiatric hospital, found zero cases of dissociative identity disorder. This study was conducted over a period of 10 years (Chaturvedi et al., 2010).

Additionally, a comparison of two separate samples of children and adolescents with diagnoses of dissociative disorders, demonstrated high construct validity for these diagnoses of dissociation in childhood. Several descriptive analyses of the total sample revealed a significant clinical profile. This clinical profile was characterized by affective (short term or immediately observable state of emotion or mood), anxiety, post traumatic, conduct, and evident dissociative symptoms.

Children with dissociative identity disorder differ from those with dissociative disorder, and dissociative disorder not otherwise specified (DDNOS). They experience considerably heightened and much severe states of amnesias, personal identity disturbance, and also psychotic symptoms such as visual or auditory hallucinations. Adolescents, on the other hand, were found to be comparatively more symptomatic than children of age 11 or younger. Adolescents were also relatively more likely to receive a diagnosis of dissociative identity disorder.

In conclusion, in spite of its lengthy and auspicious place in the history of world psychiatry, dissociation, and its types of disorders have always been associated with certain clinical or cultural controversy. A large number of in depth studies have been conducted on this all around the world, in all cultural groups, some with generalisable results, and some with not. However there is no denying that it is in fact a very real and prevalent mental illness which causes severe impairment and leads to extreme detachment from reality.

References 

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

Butcher, J. N., Hooley, J. M., & Mineka, S. (2014). Abnormal Psychology (16th ed.). Pearson Education, Inc.

Hornstein, N. L. (1992, November). Clinical Phenomenology of Child and Adolescent Dissociative Disorders. Journal of the American Academy of Child & Adolescent Psychiatry, 31(6), 1077-1085. ScienceDirect.

Kihlstrom, J. F. (2005). Dissociative Disorders. Annual Review of Clinical Psychology, 1(1), 227-253.

Putnam, F. W. (1993, January). Dissociative disorders in children: Behavioral profiles and problems. Child Abuse & Neglect, 17(1), 39-45. ScienceDirect.